#JessIntheUS – Visiting the NYSim center

One of the most exciting things I had the opportunity to do in New York was to visit the NYSIM centre, which is housed at the NYU Langone Medical Centre.

The NYSIM opened late September in 2011 in response to the events of 9/11. It was jointly funded by several bodies and is equally accessible by several clinical organisations and universities. The center recently logged its 50,000th learner in only 4 short years.
You only have to spend a few minutes walking around and inspecting its facilities and it is apparent why it has become the primary place that students and clinicians alike come to learn, practice and simulate.

The $44 million facility boasts the best and newest equipment from examination tables, surgical scrub sinks, anaesthetic machines, emergency resus rooms, to the highest fidelity manikins.

I was fortunate enough to spend my time with Jason Konzelmann, the simulation supervisor and educator at NYSIM. We started the day with a chat about simulation, how it is currently being used in Australian to help teach paramedic students as well as my own experiences with
simulation.

I am terrified of simulation…
I revealed to Jason my feelings of anxiety, as I have been thrown into a scenario with little preparation and in front of my peers. It was almost similar to how I felt going out on road for placement for the first time. I had been nursing for so long, that history taking, obtaining obs and treating the patient accordingly were second nature to me. To suddenly be observed, assessed and dare I say, scrutinised, was utterly nerve wrecking. I felt like I was performing and trying desperately to remember my lines.

Jason really pushed me to figure out why it is I have hated my experiences participating in simulation so much. After some circling around the issues, I came to realise, it is HOW the simulations I have participated in the past have been facilitated has led me to feeling threatened. Being a distance education student, I rarely or never get the opportunity to step into a sim lab. I admit, I find it horribly daunting pretending to do my job in front of my peers, whom I may have never met, with equipment I have never seen before. It is that, combined with fear of going blank that has kept me hiding from enrolling in those subjects where I know I will face the dreaded OSCE.

The visit to NYSIM has changed my feelings about how simulation can help me learn more effectively as well as dismiss some of my irrational expectations of myself. I still feel those underlying nerves about being critiqued on how I act in a certain moment in one point of time….and of course I would always rather be assessed on a real situation without a room full of peers watching on… but that is the job.

NYSIM
There are over 100 video cameras that record each movement and decision that clinicians make during a simulation exercise. The entire simulation can then be played back during the (also recorded) debrief session. NYSIM use both actors and trained faculty to act as patients whom both provide constructive feedback to the learner.

The simulation rooms range from the typical GP or Emergency department examination rooms through to high fidelity operating theatres with full anaesthetic machines and emergency department resus rooms.

The smaller examination/ interview room style rooms allow learners to interview others without feeling the glaring eyes of those watching. A one-way mirror prevents distractions, whilst an assessor or peer is able to listen and watch the simulation from just outside the room with earphones. Across the corridor is a room which provides overall audiovisual supervision of all the examination rooms. The day I visited, several medical students were practicing patient interview skills with actors. Their peers would listen in on their interviews, whilst their teacher could maintain watch over all interviews and selectively listen in on specific rooms as desired.

Further up the corridor are several large rooms, which can be converted into ward style spaces or emergency room bays. FDNY paramedics were training the day I attended and so I could not get in to take photos. However, it was more pertinent to me, that the NYSIM facilities were also considered highly beneficial for the use of paramedic students and that they also have access to the center.

Simulation is certainly not new when it comes to training student paramedics, however it is perhaps not as widely utilised as it is for nursing and medical students. (Boyle, Williams & Burgess, 2007)

NYSIM staff includes those from various backgrounds including nursing, medicine, education, paramedicine and administration.

The equipment and mannequins are the most up to date Laerdal can supply.
A quick stop into the storeroom made me soon realise, that you could almost simulate every procedure known to medicine. From arterial lines, to ABG’s and ultrasounds to uterine hemorrhages, the NYSIM has the ability to simulate almost any scenario learners need to perfect. This includes the necessity to know necessary drugs, their reconstitutions and doses. Debrief sessions may include questioning why one drug was chosen over another.

Around the corner is where it gets even more interesting. There is a full theatre scrub sink, with a staged operating theatre with all the usual equipment and anaesthetic machines. This is followed by another emergency bay

The rooms are equipped with microphones, speakers and cameras. Those participating in the simulation can question the patient just as normal, whilst specially placed speakers under the mannequin can respond.

The control room has two microphone outlets; one to speak over loudspeaker to all in the room and another to speak through the mannequin. Several cameras are placed inside the room to record each moment both audio and visual. Rooms can interconnect via a retractable whiteboard-wall, which means that learners can also simulate mass casualty presentations.

Students often feel the need to blame less than optimal performance during a simulation on any range of reasons; from lack of coffee, to lack of familiarity with the equipment. Me? I have just got stage fright.

Before commencing a learning program at NYSIM, students have the opportunity to familiarise themselves with all the equipment they will be using. Thus, they cannot lay blame on this. Students must feel confident within themselves and appreciate the knowledge and skills they possess before they can feel secure entering simulations with their peers. They must also recognise what their teachers acknowledge and expect of them.

What about prehospital simulation?
The NYSIM was not designed or built for prehospital training, nor is it the most appropriate facility to train future paramedics…
BUT what IF, we took the fidelity, the funding, equipment and ideals that NYSIM have established and created a high fidelity prehospital SIM Center? With cramped lounge rooms, freezing roadside settings, and disastrous car crashes. $44 million could create the ultimate facility to equip paramedics with the skills, spacial awareness and experience to be prepared for some of the most demanding jobs we face these days.

I can picture it in my mind, the state of the art prehospital simulation center; encompassing all manner of scenarios that paramedics may traipse upon at stupid o’clock. If we really wanted to get high tech, we could induce rain or extreme heat.

Insitu simulation is becoming ‘all the rage’. Insitu simulation is about simulating incidents in the place that they would occur with the usual people who would be involved. It does not necessarily involved a functioning sim lab.

Could I suggest you check out ‪@SimNinja3688‬‬‪ ‬for some of his low cost, yet effective simulations he has used to assess his graduate paramedics in South Australia. ‬‬

The NYSim also run some excellent and highly beneficial courses in simulation for both the teacher and learner.. You really should take a look and get along. We would be interested in sharing your review of their programs.

http://nysimcenter.org/learn/nysim-courses

I would sincerely like to thank Jason Konzelmann and Dr Demian Szyld (Associate Medical Director) for their incredibly warm hospitality and for committing their time to showing me around both the NYSIM and the Bellevue Emergency department. The tour was insightful and has given me a greater understanding of the workings of both the U.S healthcare system as well as what type of facilities would constitute the best prehospital training centre.

I had planned to integrate some of the current literature into this article, but there has been so much to say..

It is important to review the research yourself regarding the efficacy of simulation for prehospital providers (and students).
So please let me provide you with some links:

Using Advanced Simulation for Recognition and Correction of Gaps in Airway and Breathing Management Skills in Prehospital Trauma Care
http://journals.lww.com/anesthesiaanalgesia/Abstract/2005/03000/Using_Advanced_Simulation_for_Recognition_and.34.aspx

Jess Morton

Student Paramedic.

I am an Australian undergraduate Student Paramedic. I study part-time as I am also Mum to 2 beautiful boys. I am passionate about Friendship, Family & #FOAMed.
I am keen to get more experienced as well as student Paramedics into the FOAM world to enable better access to education to result in better patient care.
My interests include photography, thick shakes and sleeping in past 6am.